Chronic kidney disease (CKD) is a common and costly condition affecting more than 10% of the U.S. population. It is associated with a high risk of developing and dying from cardiovascular disease and in its advanced stages is associated with cardiovascular mortality rates approaching 10% annually. Despite the high risk and the increasing size of the CKD population quality information on the treatment of cardiovascular disease in the setting of at least moderate renal impairment remains sparse. Given the major differences in underlying all-cause mortality rates, cardiovascular pathophysiology and cardiovascular risk factors in individuals with and without CKD, standard approaches to cardiovascular care used in the general population are likely to need modification in the setting of significant CKD. The best approach to the treatment of cardiovascular disease in individuals with CKD therefore remains uncertain, and analysis of the risk and benefits of cardiovascular therapies in patients with CKD is needed in order to improve utilization and optimize outcomes in this growing high-risk population. This is particularly true in the case of coronary revascularization therapies. Both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are widely used in patients with CKD, but procedural risks associated with these therapies are high in patients with CKD and their long-term efficacy in this setting is poorly understood. We propose a series of analyses using a unique data-set of individual patients enrolled in randomized trials comparing CABG and PCI which will create an evidence base that will allow for more optimal use of CABG and PCI in patients with CKD. The relative efficacy of CABG compared with PCI for preventing death, major cardiovascular events and repeat revascularization in patients with CKD will be assessed, and predictors of success with CABG and PCI and risk factors for adverse outcomes with each procedure will be identified. To facilitate these analyses aggregated, patient-level data from randomized clinical trials comparing CABG and PCI will be collected, cleaned and assembled into a unique, unified database by the investigators This data set will be used to perform crucial analyses that will provide the fundamental information needed to: 1) allow for evidence-based, optimal use of CABG and PCI in patients with CKD;2) permit individualized decision-making regarding the choice between CABG and PCI on the basis of pertinent patient characteristics and risk factors;and 3) provide a crucial foundation of data on incidence, risks, outcomes and costs upon which future clinical trials and cost- effectiveness studies can be built. PUBLIC HEALTH RELEVANCE: Project Narrative: Chronic kidney disease (CKD) is a common condition affecting more than 10% of the U.S. population, associated with high risks of cardiovascular death and accounting for more than 10% of Medicare funding. Nevertheless, quality information on the treatment of cardiovascular disease in patients with CKD is sparse. The current application proposes analyses designed to lead to more efficient use of health care resources and better cardiovascular and overall outcomes in this growing, and high-risk population.